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Background: Femoral bone metastases (FBM) or lesions (FBL) can lead to loss of mobility and independence due to skeletal-related events (SRE), e.g. pain, deformity and pathological fractures. Aim of this study was to analyze effects of radiotherapy and surgery, different surgical techniques and complications on disease-specific survival (DSS). Methods: Patients who underwent palliative therapy for FBM or FBL between 2014 and 2020 were retrospectively analyzed. Chi-square test was used to detect intergroup differences. Survival was calculated using Kaplan-Meier method, Cox regression and compared using log-rank test. Complications were evaluated using Chi-Square test. Results: 145 patients were treated for proximal femoral BM/BL or pathologic fractures (10 bilaterally). Three groups were classified: surgery only (S, n = 53), surgery with adjuvant radiation (S + RT, n = 58), and primary radiation only (RT, n = 44). Most common primary tumors were breast (n = 31), prostate (n = 27), and non-small cell lung cancer (n = 27). 47 patients underwent surgery for an impending, 61 for a manifest pathological fracture. There were no significant differences in DSS between the 3 groups (S = 29.8, S + RT = 32.2, RT = 27.1 months), with the S + RT group having the longest one-year survival. Local complications occurred in 25 of 145 patients after a mean interval of 9.9 months. Conclusion: Due to the steadily increasing incidence and survival of patients with FBM/FBL, indication for prevention and treatment of painful and immobilizing SREs should be critically assessed. Surgical treatment should always be performed with maximum stability and, whenever possible, adjuvant RT. [ABSTRACT FROM AUTHOR]

Introduction: Hydatid disease is uncommon in Humans. It rarely affects the bones and joints (0.5–4%). Frequent sites of bony involvement are vertebrae, pelvic bones, upper end of long bones e.g. humerus, femur and tibia. Material and methods: We report a case of 41-year old female with primary Hydatid cyst of the entire right femur. Patient complaint of severe pain and was non ambulatory since the last 2 months. Results: Here, single staged Total Right Femur Replacement was done under General Anaesthesia. Patient was discharged after 6 days of hospital stay in a stable condition where physical rehabilitation was initiated after day one of the surgery, progressing to aided walking, standing and active lower limb exercises. Conclusion: Involvement of the entire femur was a challenging case. There is no consensus/gold standard treatment of severe cases. Given the involvement of the entire Right Femur along with spillage in the neighbouring muscles, patient underwent Total Femur Replacement with Hip and Knee Replacement. [ABSTRACT FROM AUTHOR]

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Abstract Background Femoral bone metastases (FBM) or lesions (FBL) can lead to loss of mobility and independence due to skeletal-related events (SRE), e.g. pain, deformity and pathological fractures. Aim of this study was to analyze effects of radiotherapy and surgery, different surgical techniques and complications on disease-specific survival (DSS). Methods Patients who underwent palliative therapy for FBM or FBL between 2014 and 2020 were retrospectively analyzed. Chi-square test was used to detect intergroup differences. Survival was calculated using Kaplan-Meier method, Cox regression and compared using log-rank test. Complications were evaluated using Chi-Square test. Results 145 patients were treated for proximal femoral BM/BL or pathologic fractures (10 bilaterally). Three groups were classified: surgery only (S, n = 53), surgery with adjuvant radiation (S + RT, n = 58), and primary radiation only (RT, n = 44). Most common primary tumors were breast (n = 31), prostate (n = 27), and non-small cell lung cancer (n = 27). 47 patients underwent surgery for an impending, 61 for a manifest pathological fracture. There were no significant differences in DSS between the 3 groups (S = 29.8, S + RT = 32.2, RT = 27.1 months), with the S + RT group having the longest one-year survival. Local complications occurred in 25 of 145 patients after a mean interval of 9.9 months. Conclusion Due to the steadily increasing incidence and survival of patients with FBM/FBL, indication for prevention and treatment of painful and immobilizing SREs should be critically assessed. Surgical treatment should always be performed with maximum stability and, whenever possible, adjuvant RT.

Pseudohypoparathyroidism (PHP) is a group of disorders characterized by end-organ resistance to parathyroid hormone (PTH), resulting in high serum PTH, low calcium, and high phosphate levels. Among its 5 subtypes, PHP type 1a is the most common and leads to hereditary osteodystrophy, marked by short stature, short metacarpals, and electrolyte abnormalities such as hyperphosphatemia and hypocalcemia, which can cause tetany and seizures. Rarely, PHP patients can experience pathological fractures of long bones. This report discusses a 22-year-old female with PHP who presented with myoclonic seizures and bilateral hip fractures. Initial symptoms included fits, flank pain, and later, leg weakness. Diagnosis was based on clinical history, elevated serum PTH, low calcium, high phosphate, bilateral cataracts, hypothyroidism, basal ganglia calcification, and family history. Treatment began with IV calcium, followed by alfacalcidol, oral calcium, and antibiotics, leading to symptom remission. Hip fractures were managed with a POP cast and later closed reduction. The patient was discharged with calcium and 1,25 dihydroxy Vitamin D supplementation and scheduled for regular follow-up.

Mandibular bone defects are a common problem and difficult to manage. A defected area mostly left to heal spontaneously. It doesn't have a definite protocol in the literature, when the area will be left to heal spontaneously or when supported with materials such as plates, screws, grafts, especially in intermediate-sized defects. In this study, it was aimed to determine by examining the areas where the stresses due to chewing forces are concentrated on the mandible bone and the risk of fracture in intermediate size unicortical and bicortical defects. The all defect models which was the residual bone heights were 6, 8, 10 mm in mandibular corpus region were created. Two different loading scenarios were applied anterior and defected premolar side. Von Mises, Pmax and Pmin stresses in models were evaluated by three-dimensional finite element analysis method. The study found higher stress accumulation on the buccal anterior side of defects in both unicortical and bicortical models, with the most stress concentrated at the buccal corners. Under Loading 1, bicortical defects with 10 mm residual bone height showed slightly higher stress accumulations than unicortical defects, while bicortical defects with 8 and 6 mm residual bone height exhibited significantly higher stress values. Under Loading 2, stress accumulations in bicortical defects were higher than in unicortical defects, with bicortical defects at 6 mm residual bone height showing almost double the stress values. Pmax stress values were higher in bicortical defects under both loadings, especially when the residual bone height decreased. Pmin stress values were comparable in unicortical defects but were higher in bicortical defects, particularly at 6 mm residual bone height, under both loading conditions. This study was presented that mandibular resistance decreases significantly when residual bone height is less than 10 mm for bicortical defects and less than 8 mm at unicortical defects. In these conditions it may need supported with materials to prevent fractures. However, in vivo and in vitro studies are necessary for definitive conclusions. [ABSTRACT FROM AUTHOR]

Background: Prevalence of pathological fractures in palliative care is less studied. This study aimed to determine the annual prevalence of pathological fractures and describe the characteristics and treatments in patients with pathological fractures referred to a specialist palliative care clinic in a tertiary care cancer center in India. Methods: Data of adult cancer patients newly referred to the specialist palliative care clinic over 1 year with a clinico-radiological diagnosis of pathological fracture was included. Key outcomes of interest were annual prevalence, clinical characteristics, symptoms and treatments offered. Results: 75 out of 5800 (1.29%) patients newly referred to the clinic over 1 year had pathological fractures. Lung cancer was the most common primary diagnosis (n = 23).Dorsal spine (n = 25) was the most common site of fracture. Pain was the predominant symptom. Mean pain score was 7.04(SD = 1.75) and 42 patients (56%) required strong opioids for analgesia. Only 11 (16%) patients underwent surgical fixation. Median duration from diagnosis of cancer to occurrence of fracture was found to be 329 days. Treatment goals changed to best supportive care in 33 patients (44%) post fracture. Patients with bone and soft tissue neoplasms and those who received only chemotherapy previously had a higher risk of occurrence of fractures. Conclusion: Annual prevalence of pathological fractures in patients referred to the specialist palliative care clinic was 1.29%. It was associated with significant symptom burden and affected oncological treatments. Close monitoring of patients with bone metastases is crucial and proactive implementation of prophylactic measures to prevent such skeletal related events is warranted. [ABSTRACT FROM AUTHOR]

Abstract Background Osteoporosis with pathological fractures is a significant public health issue, contributing to morbidity, disability, diminished quality of life, and increased mortality. Understanding mortality trends related to this condition is crucial for developing effective interventions to reduce mortality and improve healthcare outcomes. This study aimed to analyze trends and causes of death associated with osteoporosis and pathological fractures in the United States using a multi-cause approach. Methods Annual death and age-standardized mortality rate (ASMR) data from 1999 to 2020 were obtained from the Centers for Disease Control and Prevention (CDC) mortality database. Death certificates listing ICD-10 M82 (osteoporosis with pathological fracture) as an underlying or related cause of death were analyzed. Epidemiological data were analyzed, and the ASMR data were calculated for each year, and trends were assessed using the Cochran-Armitage trend test. Results From 1999 to 2020, there were 40,441 deaths related to osteoporosis with pathological fractures in the United States, with a female-to-male ratio of 5.6:1. Among these, 12,820 deaths (31.7%) listed osteoporosis with pathological fractures as the underlying cause of death (UCD), yielding a female-to-male ASMR ratio of approximately 5.0-7.7:1. When classified as a non-UCD, the ASMR ratio was approximately 4.8–6.2:1. At the same time, we found that the total number of deaths classified as UCD and multiple causes of death (MCD), but the trend ratio of the two groups in different years did not change statistically significant (P > 0.05), and the ASMR of both groups showed a downward trend. The UCD-to-MCD ratio increased between 1999 and 2007, then decreased from 2007 to 2020. As MCD, the number of female deaths was more than that of male, and both showed a decreasing trend, but there was no statistical significance in the change of trend ratio in different years (P > 0.05). Deaths were predominantly concentrated in individuals over 75 years of age, with those over 84 years being the most affected. The number of deaths in different age groups showed a decreasing trend, and the change of trend ratio in different years was statistically significant (P

Background: Osteoporosis with pathological fractures is a significant public health issue, contributing to morbidity, disability, diminished quality of life, and increased mortality. Understanding mortality trends related to this condition is crucial for developing effective interventions to reduce mortality and improve healthcare outcomes. This study aimed to analyze trends and causes of death associated with osteoporosis and pathological fractures in the United States using a multi-cause approach. Methods: Annual death and age-standardized mortality rate (ASMR) data from 1999 to 2020 were obtained from the Centers for Disease Control and Prevention (CDC) mortality database. Death certificates listing ICD-10 M82 (osteoporosis with pathological fracture) as an underlying or related cause of death were analyzed. Epidemiological data were analyzed, and the ASMR data were calculated for each year, and trends were assessed using the Cochran-Armitage trend test. Results: From 1999 to 2020, there were 40,441 deaths related to osteoporosis with pathological fractures in the United States, with a female-to-male ratio of 5.6:1. Among these, 12,820 deaths (31.7%) listed osteoporosis with pathological fractures as the underlying cause of death (UCD), yielding a female-to-male ASMR ratio of approximately 5.0-7.7:1. When classified as a non-UCD, the ASMR ratio was approximately 4.8–6.2:1. At the same time, we found that the total number of deaths classified as UCD and multiple causes of death (MCD), but the trend ratio of the two groups in different years did not change statistically significant (P > 0.05), and the ASMR of both groups showed a downward trend. The UCD-to-MCD ratio increased between 1999 and 2007, then decreased from 2007 to 2020. As MCD, the number of female deaths was more than that of male, and both showed a decreasing trend, but there was no statistical significance in the change of trend ratio in different years (P > 0.05). Deaths were predominantly concentrated in individuals over 75 years of age, with those over 84 years being the most affected. The number of deaths in different age groups showed a decreasing trend, and the change of trend ratio in different years was statistically significant (P < 0.05). White individuals had the highest number of deaths. The leading causes of death were heart diseases, chronic lower respiratory diseases, and alzheimer's disease. In addition, the number of deaths of patients with prostate cancer and breast cancer showed a significant downward trend, and the change of trend ratio between the two groups in different years was statistically significant (P < 0.05). Conclusions: Although mortality from osteoporosis with pathological fractures is decreasing, anti-osteoporosis therapy remains essential for elderly patients. Healthcare providers should remain vigilant for potential complications, including malignant neoplasms, and ensure timely diagnosis and treatment to further reduce mortality in this population. [ABSTRACT FROM AUTHOR]

Purpose: Metastatic disease of the pelvis is frequently associated with severe pain and impaired ambulatory function. Depending on the patient's characteristics, primary tumor, and metastatic pelvic disease, the treatment choice may be varied. This study aims to report on the current management options of metastatic pelvic disease. Methods: We comprehensively researched multiple databases and evaluated essential studies about current concepts of managing a metastatic bone disease of the pelvis, focusing on specific indications as well as on the result of treatment. Results: Pelvic metastases not in the periacetabular region can be managed with modification of weight-bearing, analgesics, bisphosphonates, chemotherapy and/or radiotherapy. Minimally invasive approaches include radiofrequency ablation, cryoablation, embolization, percutaneous osteoplasty, and percutaneous screw placement. Pathological or impending periacetabular fracture, excessive periacetabular bone defect, radioresistant tumor, and persistent debilitating pain despite non-surgical treatment and/or minimally invasive procedures can be managed with different surgical techniques. Overall, treatment can be divided into nonoperative, minimally invasive, and operative based on specific indications, the expectations of the patient and the lesion. Conclusion: Different treatment modalities exist to manage metastatic pelvic bone disease. Decision-making for the most appropriate treatment should be made with a multidisciplinary approach based on a case-by-case basis. [ABSTRACT FROM AUTHOR]

This case report presents the unique occurrence of a pathological fracture in the subtrochanteric area of the left femur in a 7-year-old boy, attributed to a nonossifying fibroma (NOF). NOFs are benign bone lesions commonly found in pediatric patients, but complications leading to fractures are relatively rare. The clinical presentation, diagnostic workup, and management of this case are discussed to highlight the importance of recognizing and addressing such conditions in the pediatric population.

Abstract Elastic stable intramedullary nailing (ESIN) internal fixation is used clinically to treat pathological fractures of bone cysts in children. However, one of the most important complications was removal difficulty. In this study, we aim to analyse the factors which can influence ESIN removal in healed bone cysts in children. From April 2014 to November 2020, the clinical data of 49 children who underwent elastic stable intramedullary nail removal for pathological fractures of the bone cysts in our hospital were retrospectively analysed. The following data, including age, sex, pathological fracture site, with bone graft, number of ESINs, ESIN indwelling time, and extraosseous length of ESIN were collected, and univariate analysis and logistic regression analysis was performed. The frequency of difficulty in ESIN extraction was 44.90% (22/49). The univariate logistic regression analysis showed that age,ESIN indwelling time,with bone garft and extraosseous length of ESIN may be correlated with the difficulty in removing ESIN (P 0.05).The multivariate logistic regression analysis showed that the ESIN indwelling time was the independent influencing factor for difficulty in removing ESIN (P

This article provides an overview of spinal fractures, particularly aimed at those preparing for their MRCS examinations. It begins with basic spinal anatomy and biomechanics, emphasizing the delicate balance between stability and mobility within different regions of the spine. The distinction between traumatic and pathological fractures is clarified, stressing the importance of a thorough initial assessment, including the history, examination and differential diagnosis. The article examines key classification systems (Denis Three-Column Model, AO), emphasizing their role in assessing fracture stability and guiding treatment decisions. Initial management principles are outlined, including immobilization strategies, the importance of communication with a tertiary spinal centre, and the appropriate investigations to be considered. Specific focus is given to high-risk traumatic fractures including C2 peg fractures, Jefferson fractures, Hangman fractures, Chance fractures, and tear-drop fractures. It highlights their mechanisms, typical presentations, and management considerations. The discussion of pathological fractures concentrates predominantly on osteoporosis and malignancy, but also goes into detail about spinal fractures in ankylosing spondylitis and DISH, where due to the respective pathologies, the spinal fractures that do occur tend to be atypical, unstable and compounded by challenging decision making and surgery. Finally, the article offers a brief overview of treatment aims (pain control, stability, neurological preservation) and surgical approaches (posterior instrumentation, anterior decompression and fusion). It emphasizes the importance of early assessment and management of spinal fractures, highlighting the need for multidisciplinary, patient-centred care. [ABSTRACT FROM AUTHOR]

Background: Long bones are commonly affected by musculoskeletal tumors, but they also represent one of the most frequent locations for metastases. The treatment is based on pain management and the prevention or stabilization of pathological fractures by intramedullary nailing. While titanium nails are probably the most used, carbon-fiber-reinforced (CFR) nails have emerged as a new option for oncological patients. The aim of this review is to compare titanium and CFR nails according to current findings. Methods: Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards were followed: a total of 1004 articles were identified and 10 were included. Results: Traditionally, titanium implants are highly valued for their optimal biomechanical properties and ease of insertion, facilitated by their radiopacity. However, the use of titanium poses challenges in radiotherapy due to interference with radiation dosage and the creation of ferromagnetic artifacts. Conversely, CFR implants have emerged as a recommended option for intramedullary fixation, due to their biomechanical and structural properties and their benefits during radiotherapy and follow-up monitoring X-ray. Conclusions: CFR nailing represents a promising advancement in the surgical management of oncological patients with long bone metastases. However, further studies are needed to increase surgeons' confidence in their use. [ABSTRACT FROM AUTHOR]

Background: Aneurysmal bone cysts (ABCs) are osteolytic, non-malignant, vascular lesions of the bone. Pathological fractures can be a manifestation of the ABCs, which occur in about 8% of ABCs. Different treatments have been described in the literature, but, nowadays, an optimal management of the pathological fractures in patients with ABCs is still a matter of debate and there are no standard guidelines for treatment nor any shared indication about the best surgical intervention. The aim of our study is to review the current literature available on this matter exploring and confronting different surgical treatments for pathological fractures in ABC in order to clarify the surgical approach to these patients. Methods: A systematic review of the literature indexed in PubMed, MEDLINE, and Cochrane Library databases was carried out. The Preferred Reporting Items for Systematically Reviews and Meta-Analyses (PRISMA) were followed. Results: A total of 37 articles were relevant and were finally included in the study. In total, we reached a population of 140 patients. Of the 140 patients included in the review, 124 patients (88.6%) underwent curettage surgery, 15 patients (10.7%) underwent en bloc resection surgery. A total of 47% of patients (70) underwent synthesis surgery with a plate, screw, nail, or external fixator. Adjuvant treatments were used in 8.6% of patients (12). Complications involved 20.7% of the patients (29). Conclusions: In conclusion, the treatment of pathological fractures in aneurysmal bone cysts requires careful patient assessment, considering factors such as age, the presence of open growth plates, the location of the lesion, and the surgeon's expertise. [ABSTRACT FROM AUTHOR]

Purpose: To determine whether synthetic grafts are a satisfactory treatment option for pathological proximal femoral fractures in children. Methods: Paediatric patients treated for pathological fractures of the proximal femur between 2013 and 2020 were evaluated retrospectively. 17 patients with a mean age of 10.7 years (range 6–16 years) were assessed. The definitive histopathological diagnoses were SBC (simple bone cyst) (12) and ABC (aneurysmal bone cyst) (5). The median duration of follow-up was 37 months (range 12–70 months). Results: All patients returned to their normal daily routine within 3–8 months following surgery. The mean post-op recovery time was 3.2 months (range 3–6 months). Graft was incorporated at approximately 12 months. No significant radiographic healing was observed in 2 patients. In the remaining 15 patients, the mean duration of healing was 14 months (range 8–24 months). Conclusion: Synthetic grafts are a satisfactory treatment option for pathological proximal femoral fractures in children. [ABSTRACT FROM AUTHOR]

This case report presents the unique occurrence of a pathological fracture in the subtrochanteric area of the left femur in a 7-year-old boy, attributed to a nonossifying fibroma (NOF). NOFs are benign bone lesions commonly found in pediatric patients, but complications leading to fractures are relatively rare. The clinical presentation, diagnostic workup, and management of this case are discussed to highlight the importance of recognizing and addressing such conditions in the pediatric population. [ABSTRACT FROM AUTHOR]

Primary hyperparathyroidism (PHPT) typically results from parathyroid adenoma, multiglandular hyperplasia, or parathyroid carcinoma. Patients usually present with skeletal manifestations such as low-trauma fractures. Osteitis fibrosa cystica (OFC) is a classic yet rare skeletal manifestation of advanced PHPT currently reported in less than 2% of patients. We present a case of a 29-year-old Indian female who presented with a femur fracture and mandibular OFC 20 days after delivery. The painless mandibular swelling gradually progressed from the third month of pregnancy. The biochemical and radiological investigations were indicative of PHPT-associated OFC. After the excision of the three-and-a-half parathyroid gland, histology revealed benign cystic adenomas and hyperplasia. Based on the associated clinical manifestations, OFC was suspected. Clinical exome sequencing revealed CDC73(+) c.687_688dupAG heterogenous pathogenic autosomal dominant mutation. Undiagnosed PHPT in mothers during pregnancy led to neonatal hypocalcaemic convulsions. With adequate supplementation, the infant recovered completely from transient congenital hypoparathyroidism. OFC is an important diagnosis to consider in a young patient with swelling of the neck and jaw. Simultaneous high levels of PTH and serum calcium should raise a high index of suspicion for OFC. Parathyroidectomy helps manage the biochemical abnormalities and causes regression of the jaw mass that causes facial disfigurement and attenuates the declining BMD. Children born to mothers with PHPT should be evaluated for neonatal hypoparathyroidism and supplemented appropriately to reduce the risk of hypocalcaemic manifestations that can be life-threatening. If the CDC73 mutation is detected, the offspring should be monitored for signs of PHPT due to the high probability of inheritance and parathyroid malignancy.

Fracture callus formation is a dynamic stage of bone activity and repair with precise, spatially localized gene expression. Metastatic breast cancer impairs fracture healing by disrupting bone homeostasis and imparting an altered genomic profile. Previous sequencing techniques such as single-cell RNA and in situ hybridization are limited by missing spatial context and low throughput, respectively. We present a preliminary approach using the Visium CytAssist spatial transcriptomics platform to provide the first spatially intact characterization of genetic expression changes within an orthopedic model of impaired fracture healing. Tissue slides prepared from BALB/c mice with or without MDA-MB-231 metastatic breast cancer cells were used. Both unsupervised clustering and histology-based annotations were performed to identify the hard callus, soft callus, and interzone for differential gene expression between the wild-type and pathological fracture model. The spatial transcriptomics platform successfully localized validated genes of the hard (Dmp1, Sost) and soft callus (Acan, Col2a1). The fibrous interzone was identified as a region of extensive genomic heterogeneity. MDA-MB-231 samples demonstrated downregulation of the critical bone matrix and structural regulators that may explain the weakened bone structure of pathological fractures. Spatial transcriptomics may represent a valuable tool in orthopedic research by providing temporal and spatial context. [ABSTRACT FROM AUTHOR]

The article examines nurses challenges in caring for patients with bone metastases and the impact of Bone Metastasis Cancer Board participation on nursing practice. It emphasizes improved symptom management, psychosocial support, and care coordination through multidisciplinary collaboration. It underscore the need for enhanced communication and knowledge exchange among nurses, leading to better patient outcomes.

Grade 3 proximal humerus giant cell tumours are uncommon and the results of their surgical management with prosthetic replacement are not well established. We retrospectively studied patients with grade 3 giant cell tumours of proximal humerus treated with excision and prosthetic replacement from January 2009 and December 2018. We identified 13 patients who underwent tumour excision and prosthetic replacement. There were 7 (53.8%) men and 6 (46.2%) women. The mean age at diagnosis was 30.4 years (range 16–48 years). The mean follow-up period was 72.2 months (range 24–132). Margins were positive in 4 (30.8%) patients, ≤ 1 mm in 8 (61.5%) patients, and negative in 1 (7.7%) patient. Local recurrence was seen in 2 (15.4%) patients. 1 out of 2 (50%) patients with local recurrence had pathological fracture at presentation and margins were positive in both (100%) patients. There were 3 (23.1%) complications—1 patient with joint subluxation, 1 patient with fracture post trauma, and 1 patient with surgical site infection. The mean overall Musculoskeletal Tumour Society score was 24 out of 30 (range 21–29). Resection of grade 3 proximal humerus giant cell tumour and reconstruction with prosthesis results in low recurrence rate and good functional outcome and is a valuable treatment option for such tumours. [ABSTRACT FROM AUTHOR]

Multiple myeloma is the most common primary malignant disease of the spine, which can lead to pathological fractures with consecutive instability and immobilizing pain, due to osseous destruction of individual vertebral bodies. The different surgical care is challenging, although good stabilization should be achieved if possible. The resulting blocking of micro-movements leads to pain minimization. However, this is a symptomatic therapy and does not address the primary disease. In the following, we report on successful transoral balloon kyphoplasty for the treatment of myeloma-related osteolysis with a pathological fracture of vertebral body C2, which led to a significant clinical improvement. [ABSTRACT FROM AUTHOR]

Prostate cancer is the second most common cause of malignancy in men, with bone metastases being a significant source of morbidity and mortality in advanced cases. Objective. To give a clinical example of a patient with a pathological transtrochanteric fracture of the right femur with displacement of fragments, the presence of metastasis at the fracture site, to emphasize the importance of 3D-training before surgery. Methods. A clinical example with a significant impairment of the function of the right lower extremity against the background of a significant pain syndrome is given. The diagnosis was established: pathological transtrochanteric fracture of the right femur with displacement of fragments, the presence of metastasis at the fracture site. Pre-surgical training was carried out using a 3D-model and total endoprosthetics of the right hip joint with a revision individual implant of the cement fixation type was carried out. The patient fully recovered the function of the right lower limb and hip joint, the pain syndrome was eliminated, and sleep normalized. The use of a 3D-model for preoperative training of surgeons made it possible to rationally limit traumatization of healthy tissues during tumor removal, prevent possible complications and optimize the time of surgical intervention and thus minimize blood loss. Conclusions. The use of a training 3D-model before surgery followed by prosthetics with a special oncological endoprosthesis provided satisfactory functional results and restoration of the patient's quality of life in the given clinical case. The use of a 3D-model is the key to careful preparation for surgical intervention, taking into account the individual anatomical features of the pathological process and adjacent tissues, which allows you to significantly optimize the terms of the operation and reduce blood loss, and also provides valuable experience for further surgical practice [ABSTRACT FROM AUTHOR]

Multiple myeloma or plasma cell myeloma has been described as a rare tumour in humans, cats, dogs, rats, mice, horses and a calf. Proliferation of plasma cells or plasmacytoid lymphocytes occurs. These large B lymphocytes originate primarily in the bone marrow with diffuse multifocal bone marrow involvement and bone destruction, but may also be of extramedullary origin. The result is an uncontrolled production of immunoglobulins (Igs) or Ig fragments, usually by a plasma cell clone. These Igs and their fragments are also referred to as paraproteins or M-components. Complete Ig, partial Ig, free light chains, light chain fragments or polymers can be detected. The heavy chains include, for example, the following Igs: IgG, IgA and IgM and the horse-specific IgG (T), while the light chains include kappa or lambda proteins. It is primarily a monoclonal gamma disease with Ig of the γ-region, but also IgA and IgM of the β-region and β-Ύ-globulin with an IgGA clone. Biclonal or atypical patterns may occur occasionally. Paraproteins in urine are called Bence Jones proteins. Depending on the detection of paraproteins in the serum or urine, a distinction is made between secretory and non-secretory multiple myeloma. In the case of the horse, no race or gender disposition is known. The clinical symptoms are non-specific. They correlate with the main location and spread of the neoplastic cells, the degree of plasma cell proliferation and the extent of paraproteinemia. Laboratory values vary according to the presence of secretory or non-secretory multiple myeloma. The case report of a 20-year-old polo mare presented here describes a rare disease course in non-secretory multiple myeloma with pathological fractures. The analysis and comparison with case reports already published should facilitate the diagnosis of the rare disease. [ABSTRACT FROM AUTHOR]

Osteolytic lesions refer to the destruction of any part of bone due to a disease process (pertaining to dissolution of bone, especially loss of calcium). Osteomyelitis is the inflammation of the bone caused by an infecting organism. Although bone is normally resilient to bacterial colonization, events such as trauma, surgery, infections, the presence of foreign bodies, and anemia may disrupt bony integrity and lead to the onset of bone infections. Sometimes, osteomyelitis causes no signs and symptoms or the signs and symptoms are hard to distinguish from other problems. This may be true for children, older adults, and people whose immune systems are compromised. Here, we report a case of chronic intermedullary inflammation of bone in a child. [ABSTRACT FROM AUTHOR]

PurposeThe aim of this study was to evaluate the surgical outcomes of proximal femoral bone cysts in pediatric patients.MethodsWe retrospectively analyzed 41 pediatric patients (31 males and 10 females, mean age 7.47 ± 2.67 years, range 2.03–14.67 years) diagnosed with proximal femoral bone cysts treated at a single institute between March 2009 and November 2021. Data included demographics, preoperative details, intraoperative conditions, surgical techniques, postoperative outcomes, recurrence, and complications.ResultsOf the participants, 68% presented with simple bone cysts and 32% with aneurysmal bone cysts. Prior to surgery, 32% exhibited pathological fractures. Surgical methods included lesion curettage, defect filling using allograft bone and Minimally-Invasive Injectable Graft ×3, and varied fixation techniques. Postoperative recurrence (17%) was associated with cyst location between the capital femoral epiphysis and the linea intertrochanterica (P = 0.010). At the final assessment (mean follow-up: 26.51 ± 18.99 months), all showed radiological bony union with 93% rated as “good” and 7% as ‘fair’ based on Ratliff hip scores. Complications arose in 20% of patients, significantly correlated with prior pathological fractures (P = 0.007) and their association with the linea intertrochanterica (P = 0.004). Those with fractures reported higher intraoperative blood loss (P = 0.015) and longer surgery durations (P = 0.012) compared to those without.ConclusionTreating pediatric proximal femoral bone cysts using techniques such as lesion curettage, defect filling, and selective internal fixation yields favorable outcomes. The presence of pathological fractures can prolong surgical time, increase intraoperative blood loss, and elevate postoperative complication risks. Hence, early surgical intervention for these cysts is recommended to prevent fractures.

Osteogenesis imperfecta (OI) commonly involving defects in COL1A1 and COL1A2 is a rare hereditary disease of bone fragility affecting 6–7 per 100,000 population. On the other hand, hypopituitarism is a separate entity that manifests with reduced levels of pituitary hormones. The cooccurrence of these two is seldom reported previously in literature as a deviation from Occam's razor. Here, we reported a case of pathological fracture in a 31-year-old male who had blue sclera and secondary adrenal insufficiency, hypogonadotropic hypogonadism, and growth hormone deficiency along with primary autoimmune hypothyroidism. Diagnosis of OI was suggested by heterozygous missense variant in exon 40 of the COL1A2 gene (chr7: g.94423092G > A; Depth: 99×) that resulted in the amino acid substitution of Serine for Glycine at codon 847. Replacement of glucocorticoid, levothyroxine, and testosterone was started along with antiresorptive therapy for better bone health outcomes.

Abstract Background Parathyroid carcinoma (PC) is a rare endocrine malignancy causing pathological changes such as abnormal bone metabolism, elevated serum calcium, and impaired renal function, and uncontrollable hypercalcemia is the main cause of death in PC patients. The diagnosis of PC is challenging and relying on postoperative histopathology. Radical surgery at the first time is the only effective therapy to cure PC. Hungry bone syndrome (HBS) is a relatively uncommon complication of parathyroidectomy characterized by profound and prolonged hypocalcemia, timely electrolyte monitoring and alternative interventional protocols can prevent symptomatic hypocalcemia. Case A 57‐year‐old man presented with multiple pathological fractures and muscle atrophy as the main symptoms accompanied by bone pain, hypercalcemia, elevated parathyroid hormone (PTH), and an enlarged left‐sided neck mass. After consultation of multidisciplinary team, he was treated conservatively with plaster bandage fixation and infusion of intravenous zoledronic acid; and then complete resection of parathyroid mass + removal of involved tissue structures + left thyroid and isthmus lobectomy + lymph node dissection in the VI region in left neck were performed. The postoperative histopathology suggested a diagnosis of parathyroid carcinoma. Calcium and fluid supplementation and oral levothyroxine tablets were given postoperatively. Unexpectedly, the patient's PTH level decreased rapidly at 24 h postoperative, and serum calcium and phosphorus decreased continuously, and he felt numb around perioral sites and fingertips, which considered to be postoperative HBS complicated by parathyroidectomy. Then, a large amount of calcium supplementation and vitamin D were given timely and the patient got better at 1 month postoperatively. At 9‐month postoperative, his bone pain and fatigue were significantly relieved compared with before with calcium, phosphorus, and PTH levels at normal range. Conclusion The possibility of parathyroid disease, particularly PC, should be considered in the presence of multiple pathological fractures, muscle atrophy, generalized bone pain, hypercalcemia, and clear neck mass. Radical resection of the tumor lesions at the first surgery is a key element affecting the prognosis of PC, and the effective management of preoperative hypercalcemia and postoperative HBS is also of great significance for improving prognosis.

Abstract Background The proximal femur is the most common location of metastases in the appendicular skeleton. Data on pathologic hip fractures, however, are sparse despite it is the most frequently operated pathologic fracture. The aim of this study was to investigate the ability of orthopaedic surgeons to identify pathologic hip fractures in an acute setting and secondly to validate the underlying cause of the pathologic fractures reported to Norwegian Hip Fracture Register (NHFR). Methods In the NHFR dataset between 2005 and 2019, we identified 1484 fractures reported to be pathologic possibly secondary to a malignancy. These fractures were thoroughly validated by reviewing X-rays, the patient journal, the operation description for date, side, why there had been suspicion of pathologic fracture, and implant choice. Pathology reports were reviewed once a biopsy had been performed. Based on this validation, information in the NHFR was corrected, whenever necessary. Results Of the 1484 fractures possible secondary to malignancy, 485 (32.7%) were not a pathologic fracture. When reviewing the 999 validated pathologic fractures, 15 patients had a pathologic fracture secondary to a benign lesion. The remaining 984 patients had a pathologic fracture secondary to malignancy. The underlying diagnosis reported was corrected in 442 of the 999 patients. The true rate of pathologic hip fractures secondary to malignancy in our material was 0.8%, and most patients had underlying prostate (30%), breast (20%), or lung (17%) cancer. Conclusion Orthopaedic surgeons in Norway failed to report correct data on pathologic fractures and the corresponding cancer diagnosis in an acute setting in many patients. The corrected data on pathologic fractures in the NHFR from 2005 to 2019 can now be a valid resource for further studies on the subject.

Objective To build a model of postoperative pathological fracture of the mandibular angular cystic lesions through 3D finite element analysis (FEA), to compare and analyze the biomechanical changes of the mandible after treatment with 8 types of titanium plates, and explore the reliability of titanium plate fixation in preventing pathological fracture of large mandibular cysts. Methods A 30-year-old healthy male was volunteered and the scans of cone beam computed tomography of his mandible were collected to establish a unilateral cystic lesion model of the mandibular angle region to mimic the pathological fracture caused by occlusal force loading. On the basis of the maximum critical cystic lesion size, the biomechanical characteristics and changes in the mandible with 8 different types of titanium plate fixation under the same mechanical conditions were compared. Results The risk of pathological fracture existed when the cystic lesion size in the mandibular angle exceeds 24 mm×30 mm×30 mm. The stress in the lesion area was the lowest when the upper edge was fixed with 1 mm thick titanium plate and bilateral 3 screws, and the lower edge was fixed with 2 mm thick titanium plate and bilateral 4 screws. At the same time the maximum yield strength of the mandible was not exceeded and no pathological fracture of the mandible occurred. Conclusion The incidence of pathological fracture can be reduced by using titanium plate fixation on the upper and lower margins of the mandibular angle after extraoral surgical curettage for large cystic lesions.

Introduction. Bone metastases (BM) are a significant challenge in the advanced stages of various cancers, leading to debilitating symptoms and decreased quality of life for patients. Radiotherapy (RT) plays a crucial role in managing BM by alleviating symptoms and improving local tumour control. RT for bone metastases has undergone substantial scientific and technological advancements, with external beam RT (EBRT) being the primary approach. Advanced modalities such as intensity modulated RT (IMRT) and stereotactic body RT (SBRT) have revolutionised treatment precision, resulting in improved outcomes and reduced toxicities. This narrative review aims to present the current state-of-the-art role of RT in the multidisciplinary management of patients with BM. Spinal metastases are often associated with neurological disorders, pain, and fractures. Palliative EBRT provides pain relief but – lacks sufficient local efficacy. SBRT, with its high local efficacy and tolerability, is recommended for selected cases, including previous radiation or adjuvant treatment after surgical treatment. Qualification for SBRT involves multidisciplinary collaboration and considerations of performance status, cancer progression, and available treatment options. Pathological fractures significantly impact patient performance and quality of life. Early identification of high-risk lesions using tools like the SINS scale for spinal stability and the Mirels scoring system for fracture risk assessment in long bones is crucial. Preventive surgical treatment, including prophylactic stabilisation, is recommended for impending fractures. A comprehensive multidisciplinary approach involving radiation oncologists, medical oncologists, and surgeons is crucial for developing optimal treatment plans for patients with BM. With the advancements in oncology, effective local therapy can improve patients’ chances of continuing systemic treatment and enhance their quality of life.

Abstract Background Pathological fracture of the humerus causes severe pain, limited use of the hand, and decreased quality of life. This study aimed to compare the outcomes of intramedullary nailing and locking plate in treating metastatic pathological fractures of the proximal humerus. Methods This retrospective comparison study included 45 patients (22 male, 23 female) with proximal humerus metastatic pathological fractures who underwent surgical treatment between 2011 and 2022. All data were collected from medical records and were analyzed retrospectively. Seventeen cases underwent intramedullary nailing plus cement augmentation, and 28 cases underwent locking plate plus cement augmentation. The main outcomes were pain relief, function scores, and complications. Results Among 45 patients with mean age 61.7 ± 9.7 years, 23 (51.1%) had multiple bone metastases, and 28 (62.2%) were diagnosed with impending fractures. The nailing group had significantly lower blood loss [100 (60–200) versus 500 (350–600) ml, p

Cancer of unknown primary (CUP) origin represents a diagnostic and therapeutic challenge. These tumours spread to different parts of the body even if the site of origin has not been identified. When renal metastases are observed without an obvious primary lesion, it is important to exclude the possibility of a primary kidney tumour that may be unknown or too small to be detected. The diagnosis of CUP is established after a careful clinical evaluation and diagnostic tests, including blood chemistry and laboratory tests, instrumental exams (CT, MRI, PET, bone scan), biopsy, and molecular and cytogenetic analysis. Once the diagnosis of CUP with kidney metastases is confirmed, treatment depends on the location of the metastases, the patient's health status, and available treatment options. The latter includes surgery to remove metastases, radiation therapy, or systemic treatment such as chemotherapy or immunotherapy. It is important that patients with CUP are evaluated by a multidisciplinary team of specialists, who can contribute to planning the most appropriate treatment. In this article, we report the clinical case of a patient with a pathological fracture of the proximal humerus which occurred on metastases of probable renal origin in the absence of primary lesions. [ABSTRACT FROM AUTHOR]

Myeloid sarcoma is a rare clinical entity that presents as an isolated proliferation of leukemic cells, concurrently with or at relapse of acute myeloid leukemia (AML), myelodysplastic syndromes/neoplasms (MDS), chronic myeloid leukemia (CML), and myeloproliferative neoplasm (MPN). Myeloid sarcoma disrupts the normal architecture of its surrounding tissues. When it forms in long bones, it can cause their pathological fracture. We recently experienced a rare case of MDS presenting with myeloid sarcoma in the femur that eventually resulted in its pathological fracture. Detailed chromosomal analysis of the bone marrow cells suggested emergence of myeloid sarcoma during the fast-paced progression of MDS just after acquiring trisomy 22. A comprehensive review of previous cases of myeloid sarcoma-associated pathological fracture indicated possible involvement of structural rearrangements of chromosomes 9 and 22. Management of myeloid sarcoma should continue to improve, and clinicians should note that myeloid sarcoma with specific chromosomal alterations needs extra medical attention to prevent pathological fracture. [ABSTRACT FROM AUTHOR]

Background: The proximal femur is the most common location of metastases in the appendicular skeleton. Data on pathologic hip fractures, however, are sparse despite it is the most frequently operated pathologic fracture. The aim of this study was to investigate the ability of orthopaedic surgeons to identify pathologic hip fractures in an acute setting and secondly to validate the underlying cause of the pathologic fractures reported to Norwegian Hip Fracture Register (NHFR). Methods: In the NHFR dataset between 2005 and 2019, we identified 1484 fractures reported to be pathologic possibly secondary to a malignancy. These fractures were thoroughly validated by reviewing X-rays, the patient journal, the operation description for date, side, why there had been suspicion of pathologic fracture, and implant choice. Pathology reports were reviewed once a biopsy had been performed. Based on this validation, information in the NHFR was corrected, whenever necessary. Results: Of the 1484 fractures possible secondary to malignancy, 485 (32.7%) were not a pathologic fracture. When reviewing the 999 validated pathologic fractures, 15 patients had a pathologic fracture secondary to a benign lesion. The remaining 984 patients had a pathologic fracture secondary to malignancy. The underlying diagnosis reported was corrected in 442 of the 999 patients. The true rate of pathologic hip fractures secondary to malignancy in our material was 0.8%, and most patients had underlying prostate (30%), breast (20%), or lung (17%) cancer. Conclusion: Orthopaedic surgeons in Norway failed to report correct data on pathologic fractures and the corresponding cancer diagnosis in an acute setting in many patients. The corrected data on pathologic fractures in the NHFR from 2005 to 2019 can now be a valid resource for further studies on the subject. [ABSTRACT FROM AUTHOR]

Metastases of the appendicular skeleton are the most common neoplastic process that affects the locomotor system. According to their incidence, the most common are metastases from breast, lung, kidney, thyroid gland and prostate cancer. The type of surgical intervention in patients may influence the overall survival of patients given the growing concept of oligometastases. Purpose: The aim of the paper is to show the frequency of pathological fracture in patients with metastases of the appendicular skeleton and the performed optimal surgical treatment, according to the stage and expected survival. Materials and methods: The study was conducted at the University Clinic for Orthopedic Diseases in the period between 2019-2022. It is of a retro-prospective nature. The study included 74 patients with metastases to the appendicular skeleton from primary cancers of the breast, lung, prostate, and thyroid gland. The obtained data were systematized and a statistical analysis was made. Results: According to the results of the research, breast cancer metastases are the most common, followed by lung cancer metastases. The most frequently affected region is the proximal femur, patients underwent osteosynthesis with a dynamic compression plate (DHS) and an intramedullary wedge (Intertan) respectively. In each of the patients, diagnostic investigations were performed according to the protocol: X-ray, CT, skeletal scan with tc99m. After determining the stage of the disease, patients were appropriately treated surgically, after which most were referred for adjuvant chemotherapy and palliative radiotherapy. Conclusion: The occurrence of a pathologic fracture is a catastrophic complication for most oncology patients. A clear understanding of the life expectancy of patients with bone metastases is of great help to prevent treatment errors and failures. [ABSTRACT FROM AUTHOR]

Pathological fractures occur within abnormal bone often at normal physiological load. Whilst uncommon, they should always be considered with low energy or atraumatic fractures and in those with signs, symptoms or a past medical history of malignancy. Early recognition is important as pathological fractures require investigation regarding their underlying cause before a decision regarding optimal management can be made. Elements within the patient history, examination and plane film radiographic imaging can alert clinicians to a potential pathological fracture. When suspected, a thorough work up involving systemic examination, blood tests, local and systemic staging is required to guide management. Treatment decisions are made as part of a cross specialty MDT. Expertise in the diagnosis and management of specific bone tumours with associated fractures is not expected of non specialists but an ability to recognise, investigate and appropriately refer is key for those involved in the management of patients with fractures. This article provides an overview to pathological fractures and considerations in their assessment and management. [ABSTRACT FROM AUTHOR]

Identifying risk factors for fracture occurrence in breast cancer (BC) skeletal metastases (SM) may guide the management of such bone deposits. There is sparse evidence regarding receptor status in SM and their relationship to fracture occurrence. Our study aimed to determine the relationship between estrogen (ER), progesterone (PR) and HER2 receptor status and Ki‐67 index and fracture occurrence in SM of BC. Exactly 152 samples of SM of BC obtained from individual patients were evaluated. The status of the aforementioned receptors and Ki67 index were determined in SMs samples. Their expression was compared between SM that did and did not develop a fracture. Ninety‐one cases sustained a pathological fracture at the SM site, and 61 did not. Patients who sustained a pathological fracture had a higher rate of PR positivity at their SMs as compared to those with no fracture. There was no significant difference between the two groups concerning ER, HER2+ or Ki67 status. SMs secondary to BC with a fracture are more likely to be PR positive than those with no fracture. Determining the receptor status in SMs may identify high‐risk groups for fracture occurrence, and determining the PR status may also guide surgical and hormonal therapy. [ABSTRACT FROM AUTHOR]

Aims: The modern prevalence of primary tumours causing metastatic bone disease is ill-defined in the oncological literature. Therefore, the purpose of this study is to identify the prevalence of primary tumours in the setting of metastatic bone disease, as well as reported rates of pathological fracture, postoperative complications, 90-day mortality, and 360-day mortality for each primary tumour subtype. Methods: The Premier Healthcare Database was queried to identify all patients who were diagnosed with metastatic bone disease from January 2015 to December 2020. The prevalence of all primary tumour subtypes was tabulated. Rates of long bone pathological fracture, 90-day mortality, and 360-day mortality following surgical treatment of pathological fracture were assessed for each primary tumour subtype. Patient characteristics and postoperative outcomes were analyzed based upon whether patients had impending fractures treated prophylactically versus treated completed fractures. Results: In total, 407,893 unique patients with metastatic bone disease were identified. Of the 14 primary tumours assessed, metastatic bone disease most frequently originated from lung (24.8%), prostatic (19.4%), breast (19.3%), gastrointestinal (9.4%), and urological (6.5%) malignancies. The top five malignant tumours resulting in long bone pathological fracture were renal (5.8%), myeloma (3.4%), female reproductive (3.2%), lung (2.8%), and breast (2.7%). Following treatment of pathological fractures of long bones, 90-day mortality rates were greatest for lung (12.1%), central nervous system (10.5%), lymphoma (10.4%), gastrointestinal (10.1%), and non-renal urinary (10.0%) malignancies. Finally, our study demonstrates improved 90-day and 360-day survival in patients treated for impending pathological fracture compared to completed fracture, as well as significantly lower rates of deep vein thrombosis, pulmonary embolism, urinary tract infection, and blood transfusion. Conclusion: This study defines the contemporary characteristics of primary malignancies resulting in metastatic bone disease. These data should be considered by surgeons when prognosticating patient outcomes during treatment of their metastatic bone disease. Cite this article: Bone Jt Open 2023;4(6):424–431.

This article presents a rare clinical observation of a bone form of primary hyperparathyroidism in a 16-year-old adolescent complicated by a pathological fracture of the right femur. The features of the given case are: late diagnosis of primary hyperparathyroidism in an adolescent with clinical manifestations; complication of the disease with a pathological fracture, which required two-stage treatment, open repositioning and metal plate osteosynthesis; difficulties in the organization of the examination and treatment of the patient, related to the detection of covid-19 and his stay in an infectious department; the need for tactical decision on the sequence of surgical treatment of the fracture and its cause - primary hyperparathyroidism.

Primary leiomyosarcoma of bone (PLB) is a rare tumor, constituting <0.7% of all primary bone malignancies. It is clinically aggressive with heterogeneous presentation and a dismal prognosis. The most common presentation is pain with swelling and pathological fracture at times. Limited literature is available on PLB and only about 150 cases have been reported to date with only a few case reports defining the utility of 18F‑fluorodeoxyglucose (18‑F FDG) positron emission tomography/computed tomography (PET-CT) in its management. We hereby present a case of primary leiomyosarcoma of the right distal femur and the role of FDG-PET-CT in its management. [ABSTRACT FROM AUTHOR]